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Chronic lower limb ischemia is 97 percent caused by atherosclerosis. A characteristic symptom of the disease is the so-called intermittent claudication, i.e. pain in the legs that occurs while walking and forcing the patient to stop. The pain subsides during rest, but reappears when walking is resumed. In the city, pain often stops the sick at shop windows. Hence the colloquial name of this disease: shop window disease.
In childhood, our arteries are open, flexible, and blood can flow freely. The aging process progresses over the years, and one symptom of aging is stiffness and overgrowth of arteries. The main cause of these unfavorable changes is atherosclerosis, a disease consisting in the deposition of cholesterol in the connective tissue of the blood vessel walls. Atherosclerotic plaques gradually narrow the artery, which leads to ischemia of the tissues supplied by it. Atherosclerosis is a systemic disease, it can affect the coronary arteries, which is a risk factor for a heart attack, it can attack the cerebral artery and lead to a stroke, and it can also occur in the arteries of the legs. Atherosclerosis of the lower extremities is sometimes defined differently, e.g. as peripheral arterial disease (PAOD) or leg arterial occlusive disease.
Chronic lower limb ischemia in Poland
The incidence of chronic lower limb ischemia depends on age. Most people over 55 are ill. In this age group, atherosclerotic changes in the abdominal aorta and arteries of the lower extremities are found in 20% of Europeans and North Americans. Over the age of 75, 30 percent of the population is sick. In general, men get sick twice as often as women. However, after the age of 70 and in the presence of coexisting diabetes mellitus, the incidence of lower limb ischemia becomes similar in both sexes. In Poland, there are about 30 new cases every year.
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Over 80 percent of PAOD patients are people who have smoked heavily or continue to smoke. Smokers can be up to ten times more likely to experience intermittent claudication than a non-smoker. In addition to age, gender and smoking, the risk factors for developing hardening of the arteries of the lower extremities include: a sedentary lifestyle, arterial hypertension, diabetes, and lipid disorders (elevated levels of cholesterol and triglycerides).
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Symptoms of limb ischemia
The leg muscles are relatively large and need an efficient transport of nutrients supplied by the blood for their work. Thanks to the extensive network of arteries, blood reaches from the thigh to the fingertips. However, when adverse changes occur in the arteries and the vessel lumen decreases, the muscles receive less and less fuel and slowly die. The strength of the limbs gradually weakens, and long-term walking becomes impossible. An easily noticeable symptom of progressive lower limb ischemia is a decrease in the weight and circumference of the leg. In the affected limb, the skin also reacts to ischemia: it becomes paler, cooler and thinner, and the hair disappears. In the advanced stage, difficult to heal ulcers are formed.
While walking, the muscles in the ischemic limb begin to make themselves felt with a sharp pain, which prompts the patient to stop after a certain section of the route. Over time, the distance that the patient can cover without rest becomes shorter and shorter. Depending on where the artery is narrowed, claudication pain may appear in the calf, under the knee, in the thigh, or in the buttock. The most common is femo-popliteal obstruction.
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A characteristic sign of a developing disease is the weakening of the heart rate. In a healthy person, the pulse should be well felt in all arteries that run close to the skin. When the vessel becomes atherosclerotic, its wall becomes stiff and the heartbeat becomes undetectable. On the lower limb, you can feel the pulsation of blood in the groin, under the knee, on the side of the ankle, and on the back of the foot. Self-monitoring of the pulse in these places is important, and if you do not feel it, you should urgently see a doctor.
As the ischemic process continues, the increasingly finer arteries slowly lose their patency. Then the tissues undergo necrosis due to the lack of oxygen and nutrients. The pains also begin to bother during rest, the limb becomes cold and the patient slowly loses feeling. Moving the affected leg becomes more and more difficult, and finally impossible. Complete ischemia may occur at any time, resulting in necrosis of a given section or even of the entire limb. It is a condition of critical limb ischemia.
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Degrees of limb ischemia
Grade I – characterized by mild symptoms in the form of tingling, numbness, increased sensitivity of the feet to cold.
Grade II – pain ailments related to the disease appear:
a – intermittent claudication after walking a distance of more than 200 m,
b – intermittent claudication over a distance shorter than 200 m.
Grade III – pain also occurs when resting (often at night).
Stage IV – includes ulceration and necrosis.
The concept of critical limb ischemia refers to grade III and IV ischemia according to this scale. Sometimes the only possible therapeutic procedure is amputation of the entire limb or its part.
Types of arterial obstruction
Due to the location of the lesions, chronic obstruction of the arteries of the lower extremities is divided into:
— aortoiliac – intermittent claudication is felt in the thigh or buttocks, there is atrophy of the muscles of the lower limbs, sexual impotence may occur.
— thigh-knee (in 70% of patients) – most often affecting the superficial femoral artery (claudication becomes evident after walking several hundred meters) or the peripheral artery located below the bifurcation of the popliteal artery (there is a feeling of cold, tingling, pain in the foot). Femo-popliteal obstruction often coexists with diabetes mellitus.
— multi-level – these are far-reaching ischemic changes in various sections of the arteries, and on the surface of the limb – necrotic changes.
Treatment of shop window disease
The treatment of chronic lower limb ischemia is performed by angiologists and vascular surgeons. The doctor begins the diagnostic process with a careful examination of the limb and simple measurements. The circumference of the calf below the knee fossa and the thigh above the knee is measured (with progressive ischemia, the circumference decreases). Your doctor checks for a pulse in the groin, under the knee, on the side of the ankle and on the back of the foot. It measures the systolic pressure on the arm and in the peripheral arteries: tibial posterior and / or dorsal foot. Then, on the basis of the obtained results, it calculates the so-called ankle-brachial index (ABI). This index is the quotient of the systolic pressure measured at the foot and the systolic pressure at the upper arm. In a properly supplied limb, the ABI value is 0,9 – 1,15. Comparing the resting ABI with the same measurement after exercise that was causing limb pain may provide additional information. The ABI index allows the diagnosis of asymptomatic lower limb ischemia. For the doctor, abnormal ABI values are the basis for referring the patient to imaging tests. Currently, it is most often duplex ultrasound – a non-invasive test of blood flow in the arteries and veins. The research allows, among others for the precise location of the narrowing of the arteries of the lower extremities. Magnetic resonance angiography (MR angiography) or computed tomography (angio-CT) angiography are also used. For the study of arterial flows, angiography is also still used, especially its modernized version, the so-called digital subtraction angiography. This examination allows to obtain a more accurate image of the vessels with the use of significantly less contrast agents and doses of radiation than in traditional angiography. All diagnostic tests are used to select the best method of therapy.
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Treatment of atherosclerosis – revascularization
Treatment of obstructive arteriosclerosis consists in their revascularization. This term means the widening and restoration of the narrowed blood vessel in order to restore normal blood circulation. It can be drug treatment or surgery.
Most Grade I and IIa occlusions are managed conservatively. It mainly consists in excluding the risk factors for atherosclerosis and introducing healthy habits to improve blood circulation. It is absolutely necessary to:
– quit smoking because nicotine has a toxic and constricting effect on the vascular wall and increases blood viscosity, making it difficult to flow through the limb.
– walk systematically – it is a stimulus for the development of collateral circulation;
– protect the feet from injuries, infection, the effects of cold, in order to increase the blood flow necessary to heal existing lesions;
– follow a diet low in cholesterol and saturated fatty acids;
– treat hypertension and diabetes;
– use vasodilating drugs.
Pharmacological treatment also includes: anti-aggregating (antiplatelet) drugs, i.e. drugs that thin the blood (e.g. acetylsalicylic acid) and reduce clotting (e.g. coumarin derivatives). Stage IIb, III and IV patients qualify for surgical treatment. If the stenosis is short, percutaneous angioplasty of the artery is most commonly used. After a catheter is introduced into the narrowed vessel, it is expanded with a balloon. Sometimes the wall of the so-called artery is additionally strengthened. a stent that is also intended to prevent it from narrowing again. Laser angioplasty works by burning light in a place narrowed by atherosclerotic plaques.
In the case of obstruction of long sections of the artery, vascular prostheses (artificial or transplants from the patient’s own vessels) are implanted, bypassing the obstructed section of the vessel. The last resort is a limb amputation procedure below which many arteries are closed. Eligibility for surgical treatment should take into account: the patient’s age, general condition and comorbidities.
Antiplatelet therapy is also used in patients after surgical revascularization of the artery. Systematic exercises according to special vascular programs are very important. They should be performed at least 3 times a week for 30-45 minutes. The desired form of exercise is walking and cycling. Motor rehabilitation is used to create collateral circulation. The influence of exercise, unfortunately, disappears after their discontinuation, so there must be no interruption in physical activity.
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Prophylaxis, both primary and secondary of chronic ischemia of the lower limbs, is simply anti-atherosclerotic prophylaxis and consists in not smoking, the aforementioned physical activity, following a healthy diet with lower cholesterol and saturated fatty acids (its basis should be vegetables and fish) and periodic exercise control tests. It is primarily a blood test (the so-called lipidogram) to determine the level of cholesterol broken down into HDL and LDL fractions and triglycerides, as well as the measurement of blood pressure.
Text: Barbara Skrzypińska